Stridor: a rare complication of magnesium sulfate therapy in a pregnant patient

Magnesium sulfate is frequently used in severe preeclampsia and eclampsia for the prevention and reoccurrence of seizure activity. Their adverse effects of magnesium sulfate are minor but it cause respiratory depression and tetany. We report a case of stridor due to laryngospasm as result of hypocalcemia in a pregnant patient on magnesium sulfate therapy.A 30 year old gravida5 para 4 had severe preeclampsia started on magnesium sulfate therapy and to control her hypertension she was on labetalol and nifidipine. One hour after the lower segment cesarean section, she developed severe laryngospasm and stridor, no upper airway secretion but found to have hypocalcemia. She responded to immediate intravenous calcium chloride with dramatic clinical improvement. Patients on magnesium sulfate can have life threatening hypocalcemia and stridor. The calcium channel blockers may augment the hypocalcaemic effect of magnesium sulfate

Pheochromocytoma and pregnancy with abruptio placenta

A 41 year old previously healthy woman (Gravida 4, para 3) was presented to our hospital at 29 weeks gestation, with bleeding Per Vagina (PV) and severe hypertension (190/100). She underwent a routine obstetric examination at 12 weeks gestation and since then she has not undergone any antenatal follow-up. She developed episodes of severe headache, dizziness, sweating, and nausea. She visited a private hospital and was noted to be severely hypertensive (190/120) with headache and palpitations. An ultrasound abdomen was done which showed left suprarenal mass, and   a diagnosis of pheochromocytoma was made. She was treated there with antihypertensive medications. When Blood pressure got controlled, she was discharged against medical advice. At 29 weeks, she suddenly developed severe headache and bleeding PV. She visited our centre and was diagnosed to have abruptio- placenta with foetal distress. An emergency caesarean section was done, and following which the patient was treated in the ICU with antihypertensive under invasive monitoring. An MRI demonstrated a left pheochromocytoma. A laparoscopic adrenelectomy was planned later and she got discharged on antihypertensive following an uneventful period of recovery. She got operated later in her country. A laparoscopic left adrenelectomy was done. She is off all medications now and is currently asymptomatic

Acute Pain Management in Intensive Care Patients: Facts and Figures

Pain is an unpleasant experience for all patients including intensive care patients; if it is not treated properly, it has deleterious effects on patients’ acute and chronic well-beings. In ICU patients, it causes sympathetic stimulation leading to adverse hemodynamic effects and after discharge, these patients are at the higher risk for developing chronic pain and post-traumatic stress disorders. Apart from racial and regional factors, sleep deprivation, anxiety, and delirium increase the pain perceptions. Pain assessment is a prerequisite for adequate pain management. The ICU patients are sedated and ventilated, and assessment scales differ depending on whether the patient is able to communicate. There are different pain assessment scales for both groups of patients. The preferred mode of delivery of analgesic medication is intravenous route as intramuscular and subcutaneous route are not reliable for drug delivery in these patients. Patient and nurse controlled analgesia gives better sense of pain control. In the treatment of pain, opioids are the commonly used medications, but paracetamol, dexmedetomidine, and gabapentin are increasingly used. Newer trends are multimodal analgesia, where the combinations of analgesic medications with different mechanism of action are used. Another trend is increasing use of analgosedation; they not only control the pain but also relieve anxiety

Moyamoya Disease: A Rare Vascular Disease of the CNS

Moyamoya disease (MMD) is a rare disease affecting the cerebral vasculature of the central nervous system (CNS) with a reported incidence of 0.35–0.94 per 100,000 populations. It was first reported from Japan and later from other parts of the world. The pathology is narrowing of blood vessels supplying anterior circulation and rarely posterior circulation. It was believed that the disease is genetic in origin, but environmental factors also play a role. Patients with this rare disease may present with ischemic or hemorrhagic symptoms. Ischemic symptoms account for the disease in most of the pediatric patients, whereas in adults, hemorrhage is more common. Diagnostic imaging like CT angiogram and magnetic resonance angiogram helps in demonstrating the narrowing or the collateral vessels like “a puff of smoke” (moyamoya) formed at the base of the brain. Moyamoya disease is treated medically and/or surgically. Aspirin is the main medication used. Surgical options are direct or indirect revascularization techniques to bypass the stenosis. The disease is progressive in majority of the patients, but if treated early, they can have good prognosis especially children

Acute Management of Heat Stroke: Facts and Figures

Heat-related illnesses range from heat exhaustion to heat stroke. Heat stroke is a life-threatening medical emergency causing multiple organ dysfunction that if not treated, can be fatal. It is a severe heat illness with a body temperature of more than 400c and organ dysfunction. Epidemiology of heat stroke varies depending on geographic location, and reported incidences range from 1.98 to 2.89/100000 per year. Heat stroke is classified as exertional or non-exertional. Pathophysiology is exposure to higher temperatures with impaired thermoregulation. Patients will present with high core body temperature; tachypnea, tachycardia, and hypotension may be present. The manifestations of organ dysfunction range from coagulopathy to altered levels of consciousness, and pulmonary edema. Accurate core body temperature measurement with clinical manifestations will diagnose the heat stroke. Early diagnosis, earlier temperature management, and organ supportive care are essential

Cerebral Arteriovenous Malformations (cAVMs): What Is New?

Cerebral arteriovenous malformations (cAVMs) are rare congenital anomalies of cerebral blood vessels that result from maldevelopment of the capillary bed, permitting direct communication between cerebral arteries and veins. It usually occurs in the supratentorial area of the brain; however, it can occur anywhere in the brain and spinal cord. Most of the patients with cAVMs present with a variety of complaints such as seizures, intracerebral hemorrhage, headache, and progressive focal neurological deficit. Imaging such as CT, MRI, and angiography plays a vital role in diagnosis, grading, risk assessment, and posttherapeutic follow-up. The multidisciplinary team use three therapeutic modalities in the treatment of cAVMs. This chapter reviews the clinical presentations, diagnosis, classification, and treatment of cAVMs

Urosepsis: Flow is Life

Urosepsis is one of the important etiological factors for community as well as hospital-acquired infections. Accordingly, urosepsis is divided into community-acquired and hospital-acquired urosepsis. Obstruction to the flow of urine is a common risk factor for community-acquired urosepsis, whereas the indwelling urinary catheter is the risk for the hospital-acquired urosepsis. E. coli remained the most common bacteria-causing urosepsis. If not treated early and appropriately, urosepsis can complicate into septic shock and multiple organ dysfunction. The cornerstone for the improved outcome of these patients is initial resuscitation and proper antibiotic therapy and restoring the flow of urine or removing the infected urinary catheter. Community-acquired urosepsis can be prevented by removing the obstruction to flow of urine permanently. The hospital-acquired urosepsis can be prevented by strictly following catheter-associated urinary tract infection prevention bundle and removing the catheter as early as possible

Cerebral Arteriovenous Malformation from Classification to the Management

Cerebral arteriovenous malformations (cAVMs) are the rare neurosurgical emergency. cAVM is an abnormal vascular web, composed of nidus, feeding artery and draining veins. It commonly occurs in the supratentorial area of the brain. The common grading system used in cAVM is Spetzler-Martin grading, which takes into consideration the size of nidus, the location of cAVM and the venous drainage. The cAVMs may develop flow and pressure-related aneurysms, which will increase the morbidity and mortality in these patients. cAVMs vary in size and undergo growth, remodeling and rarely regression. Most of the cAVMs are asymptomatic, but the common presentation are headache, seizure, intracerebral hemorrhage or focal neurological deficit. The cerebral angiography remains the gold standard for the diagnosis of cAVM. Management of the cAVM includes medical therapy, surgical excision, radiosurgery and embolization

Peripartum Pulmonary Embolism

Pregnancy and peripartum increase the risk of venous thromboembolism (VTE) by many folds. Interestingly, the VTE is more common during the pregnancy, whereas the pulmonary embolism is more frequent in postpartum period. There are various risk factors for the VTE and pulmonary embolism in these patients. The important risks are improper thromboprophylaxis, obesity, and multigravida. The clinical parameters and the d-dimer are not used for diagnosis of thromboembolism during pregnancy and in the postpartum period. The compression ultrasonography (CUSG) is commonly used for VTE diagnosis; for the pulmonary embolism diagnosis, one has to consider the radiation hazard to the fetus as well as to the mothers. Ventilation/perfusion scan is the imaging of choice for patient who has respiratory signs with normal chest radiograph. If chest X-ray is abnormal with suspicion of peripartum pulmonary embolism (PPE), the choice should be computed tomographic angiography. Heparin and its derivatives remained the anticoagulation of choice for the treatment of VTE as well as the PPE, as it is a shorter acting, easy to reverse with protamine sulfate. Proper thromboprophylaxis is the key for prevention of VTE and peripartum pulmonary embolism